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  • Dr Danny Marhaba

JOURNAL CLUB - JANUARY 2023

Updated: Nov 3, 2023

Journal Club Podcast January 2023

Dr Danny Marhaba Dr Rob Melvin Professor Peter Cameron

Welcome to the first Journal Club Podcast of 2023. We are joined by Professor Peter Cameron, Academic Director for the Alfred Emergency and Trauma Centre and Dr Rob Melvin, Emergency Consultant and Deputy Director at Alfred Emergency and Trauma Centre.


This month has a paediatric theme with papers looking at: immobilisation of torus fractures, the mid-arm point for paediatric ICC insertion, and screen time in paediatric concussion.


IMMOBILISATION OF TORUS FRACTURES OF THE WRIST IN CHILDREN (FORCE): A RANDOMISED CONTROLLED EQUIVALENCE TRIAL IN THE UK

READ IT HERE

CLINICAL QUESTION

Is rigid immobilisation necessary in paediatric buckle fractures of the distal radius?

JOURNAL

The Lancet, July 2022

LEAD AUTHOR

Daniel C Perry

BACKGROUND

Buckle Fractures of the distal radius are among the most common fractures in children {1}. Fractures of the distal radius can be classified as those affecting the growth plate (physis), those involving the metaphysis and/or those affecting the diaphysis. There has been a wide variation of practice recommendations in the management of buckle fractures of the distal radius, with some recommending rigid immobilisation and others recommending bandaging {2,3,4}. A 2018 Cochrane review into the treatment of buckle fractures concluded that they were unable to recommend a particular treatment strategy (partly due to the low quality of evidence), however, they did note that their review findings were consistent with the move away from cast immobilisation for buckle fractures {5}.

DESIGN

Multicentre, Randomised, Controlled, Equivalence Trial

Population665 children 8 – 15 years of age, and 300 children 4 – 7 years of age, who presented to one of 23 emergency departments in the UK, with a radiologically confirmed buckle fracture of the distal radius. Excluded were children whose injuries were ≥36 hours old, children who’s clinician suspected a cortical disruption of the radius, or those deemed unable to adhere to trial procedures (insufficient English, no internet, developmental delay, etc).


EXPOSURE

Bandage offering and immediate discharge.

ComparisonRigid immobilisation with splint, back-slab or cast and follow up as per treatment centre protocol.


OUTCOME

Primary:

  • Pain at 3 days, as measured by the WBFPS (Wong Baker Faces Pain Scale). Secondary Outcomes

  • A collection of findings including days of school or childcare absence at 3 and 6 weeks, return to hospital at 1/3/6 weeks, and patient satisfaction using a 7-item Likert scale.

FINDINGS

Primary Outcome

  • Children in the exposure group (bandage and discharge) had a mean WBFPS of 3.21, compared with 3.14 in the comparator group (rigid immobilisation), with CI -0.37, 0.17. Secondary outcomes:

  • No significant difference in pain at any measured time-point.

  • No significant difference secondary outcomes in function questionnaires.

  • Statistically significant difference in parent satisfaction on day 1 and analgesia use on day 1.

  • While not statistically significant, trend for bandage group to be more likely to have used analgesia (except D1), and have missed school.

AUTHORS' CONCLUSIONS

The authors report that their trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius, between bandage and rigid immobilisation. They also report do between-group differences in pain or function during the 6 weeks of follow up.

BOTTOM LINE

  • This trial reaffirms that a bandage or tub-grip results in equivalent outcomes, save for some increase in use of basic analgesia.

  • Splints here are a good option to have, but in this particular injury, rigid immobilisation is just not necessary – whether there is a concurrent ulnar fracture or not.

  • Orthopaedic clinics are often full, and to be able to avoid unnecessary referrals to this clinic likely represents good stewardship of social resources.

  • An equivalence trial has more steps than a traditional difference of means trial, in that one would need to disprove two null hypotheses rather than just one. The first null hypothesis to disprove is that the exposure increases the outcome variable by a certain measure of association. The second null hypothesis to disprove is that the exposure reduces the outcome variable by a certain measure of association. Disproving both, therefore shows that the exposure is equivalent to the comparator, to a certain statistical significance and minimum clinically important difference.


🎧 Podcast editor, Dave McCreary, also discussed this study on the RCEMLearning podcast, you can hear that here. 🎧



MID-ARM POINT IN PAEDIATRICS (MAPPAED): AN EFFECTIVE PROCEDURAL AID FOR SAFE PLEURAL DECOMPRESSION IN TRAUMA

READ IT HERE



CLINICAL QUESTION:

Can the Mid Arm Point be used for landmarking ICC insertion in children?


JOURNAL

Emergency Medicine Australasia, November 2022

LEAD AUTHOR

Nuala Quinn


BACKGROUND

In 2022, injuries were responsible for 33% of all deaths in Australian children {8}. Of those severely injured children, many are at risk of dying from thoracic injuries requiring emergency pleural decompression {9}. In one audit of a high-volume trauma service, 41% of intercostal catheters in children, were placed outside of the triangle of safety {10}. The Mid Arm Point is used in some adult trauma centres, and has been reported to be a reliable aid in placement {11}.

DESIGN

Prospective Cohort Study, compared to a presumed gold standard

Population (Target)392 children aged ≤18 years, who attended one of four emergency departments in Australia and Ireland, who required a chest X-ray for any reason.


POPULATION (TARGET)

392 children aged ≤18 years, who attended one of four emergency departments in Australia and Ireland, who required a chest X-ray for any reason.


EXPOSURE

Mid Arm Point measured and the chest wall marked at that level, a radio-opaque sticker was placed on the mark and an X-Ray was taken with the arms abducted.


COMPARISON

A presumed gold standard of intercostal space (ICS) 4–6, as identified on the chest x-Ray by a consultant radiologist.


OUTCOME

Primary Outcome:

  • The proportion of markers localized to ICS 4–6 by interpretation of a consultant radiologist, versus those that identified as ICS 1-3 (too cranial) and those that were identified as ICS 7-8 (too caudal).

Post Hoc Analysis:

  • The proportion of markers localised to ICS 4–6 after a single ICS adjustment for age, chosen as ≥4 years.


WHAT WERE THE FINDINGS?

  • 712 markers were placed and xrayed following exclusion criteria, 353 (50%) Left sided 359 (50%) right sided.

  • Using the MAP technique throughout all ages found 81% success, with malposition favouring more caudal placement - 14% in ICS 6th and 7th, with only 3% above 4th space.

  • Patients between age 4-18 had higher rates of malposition and of those they were largely placed too caudal (22.6%).

  • Post Hoc analyses showed an increased overall success rate to 91% if a MAPPAED rule was applied to ages 4-18 where the intercostal space above the marked space was used.

AUTHORS' CONCLUSIONS

Adopting the MAP and MAPPAED approach may improve these success rates of appropriate positioning in the safe zone, and reduce cognitive load on emergency and prehospital clinicians. The MAP rule requires a modification to ages 4-18 which likely represents non-linear relative discrepancies in growth patterns of upper limb and thoracic cage.

CLINICAL BOTTOM LINE

  • This is an excellent study. It is simple, straightforward, and represents a creative and pragmatic way to gather clinically useful evidence.

  • For most emergency physicians, ICC insertion in children is rare. Using the Mid-Arm-Point in children <4 and moving 1 ICS superiorly to the Mid-Arm-Point in children ≥4 represents a significant reduction in cognitive load for what may be a complex resuscitation.

  • Producing a good quality, prospective, randomised controlled trial in this patient group is fraught with challenges, if at all feasible. The MAPPAED study may well be some of the best evidence that exists in paediatric ICC insertion for some years to come.

  • The primary limitation however, is in the post-hoc analysis in children ≥4 years. This is because a statistical test is most valid when tested against a pre-conceived single primary outcome, as opposed to identifying a group of retrospectively generated patterns.

  • One could say that the MAPPAED rule, has been prospectively tested in children <4 years of age outside of a major trauma resuscitation, and that the MAPPAED adjustment, has been retrospectively identified in children ≥4 years of age outside of a major trauma resuscitation.


EARLY POSTINJURY SCREEN TIME AND CONCUSSION RECOVERY

READ IT HERE


CLINICAL QUESTION:

Does a reduction in screen time facilitate recovery from paediatric concussive head injuries?

JOURNAL

Pediatrics, November 2022

LEAD AUTHOR

Molly Cairncross

BACKGROUND

Screen-time restrictions are often recommended by clinicians providing care for paediatric patients with a post-concussive head injury {6}. In 2021, a randomised trial of 125 patients between 12 – 25 years of age was conducted published in JAMA-Pediatrics, and provided some much-needed evidence for this recommendation {7}. However, the actual screen-time recorded for the screen-time restricted group was a median of 130 minutes per week (compared to 630 minutes in the screen-time permitted group). Unanswered questions into the optimal screen-time recommendation therefore persist.

Design

Retrospective Cohort Study - (Planned secondary data analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) study)


POPULATION (TARGET)

Seven hundred and twelve children aged 8 – 16 years, who presented to one of five Canadian Emergency Departments, between September 2016 and December 2018, with blunt head trauma and symptoms consistent with a concussion. Exclusion criteria were children with neurological deterioration, neurosurgical intervention, LOC > 30 min, amnesia > 24hrs, and abbreviated injury scale (AIS) > 4.


EXPOSURE

Self-reported screen-time measured weekly for 3 months, in patients with a diagnosed concussive head injury.


COMPARISON

Self-reported screen-time measured weekly for 3 months, in patients with a diagnosed orthopaedic injury.


OUTCOME

Primary:

  • Differences in the association with the Health and Behaviour Scores, between the two groups, measured weekly for 3 months. Secondary Outcomes

Secondary:

  • A collection of other pre and post injury factors and measures of association with post concussive symptoms.


WHAT WERE THE FINDINGS?

  • Screen time was a significant but nonlinear moderator of group differences in post-concussion symptom severity for parent-reported somatic (P = .01) and self-reported cognitive symptoms (P = .03).

  • Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the OI group during the first 30 days postinjury but not after 30 days.

  • Other risk factors and health behaviours had stronger associations with symptom severity than screen time.

AUTHORS' CONCLUSIONS

The interaction between self-reported screen time and post concussive symptoms is not linear. They recommend moderation in screen-time rather than abstaining from it.

CLINICAL BOTTOM LINE

  • This is a retrospective cohort study of an intervention – and the study design comes with many confounders. Concussive symptoms themselves may have many modifiers on both quantity and quality of screen time – they may be simply staring at the screen rather than engaging with it.

  • Another challenge to the conclusions of the study are the nature of self-reported data on screen time. The fact that there was only a moderate correlation between parent and child – reported screen-time (Spearman’s r = .6) highlights this challenge.

  • For now, it is likely reasonable to recommend moderation in screen-time for children who have suffered a concussion.

REFERENCES

  1. Chung KC & Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am.2001; 26: 908-915

  2. National Clinical Guideline Centre (UK). Fractures (non-complex): assessment and management. (NG38). 2016. https://www.nice.org.uk/guidance/ng38

  3. Children’s Health Queensland Hospital and Health Service. Buckle Fractures . https://www.childrens.health.qld.gov.au/fact-sheet-buckle-fractures/. Accessed January 2023.

  4. Royal Children’s Hospital, Melbourne. Distal radius and / or ulna – metaphyseal fractures. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radius_and_or_ulna_metaphyseal_fractures_Emergency_Department_setting/ (Clinical Practice Guideline). Accessed January 2023.

  5. Handoll HH, Elliott J, Iheozor-Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2018 Dec 19;12(12):CD012470. doi: 10.1002/14651858.CD012470.pub2. PMID: 30566764; PMCID: PMC6516962.

  6. Queensland Health. Recovery after a concussion (Patient Fact Sheet). https://www.health.qld.gov.au/news-events/news/recovery-after-concussion. Accessed January 2023.

  7. Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion:A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124–1131. doi:10.1001/jamapediatrics.2021.2782

  8. Australian Institute of Health and Welfare. Infant and Child Deaths. https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/infant-child-deaths. Accessed January 2023.

  9. Quinn N, Palmer CS, Bernard S, Noonan M, Teague WJ. Thoracostomy in children with severe trauma: an overview of the paediatric experience in Victoria, Australia. Emergency Medicine Australasia. 2020; 32: 117–26.

  10. Kong VY, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Aftrica. Annals of the Royal College of Surgeons of England. 2014; 96: 609–13.

  11. Bing F, Fitzgerald M, Olaussen A et al. Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP). Journal of Emergency Medicine, Trauma and Acute Care 2017.Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred.



DR DANNNY MARHABA

Emergency Registrar

Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred.

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